Medicaid Global Spending Cap
January 2013 Report
Results through January 2012 - Summary
Total State Medicaid expenditures under the Medicaid Global Spending Cap for SFY 2012-13 through January are
$185 million or 1.4% below projections. Spending through January resulted in total expenditures of $13.09 billion
compared to the projection of $13.28 billion. The State is anticipating ending this fiscal year with $200 million in
savings to the Medicaid program. The savings is projected to occur as a result of lower than expected
utilization/costs in various categories of service ($130 million), higher Local Administration savings ($40 million),
and lower State Operations spending ($30 million).
30 Day Amendments: Federal Revenue Solution
The State needs to replace the existing, long-standing financing system for developmental disability services, which
will reduce federal Medicaid revenue by $1.1 billion annually. As part of the 30 Day Amendments to the 2013-14
Executive Budget released on February 21st, the Governor included actions/requirements to solve the federal
revenue problem. A comprehensive solution is necessary to ensure vital services are provided even when the
federal Medicaid funding is lost. This solution must be balanced, involve a partnership with the entire health care
community, and rely on and build off the continuing success of the MRT. Below are the actions necessary in
solving the lost federal revenue issue:
Required State Actions:
 $200 million in 2012-13 under spending to advance 2013-14 expenses.
 Acceleration of MRT initiatives and other reforms/investment delays ($180M).
 Office for people with Developmental Disabilities (OPWDD) provider rate reduction = 6% Across the
Board ($120M).
Additional Federal Revenue/Investments/Savings:
 Federal revenue from additional emergency Medicaid claiming and other possible efforts ($250M).
 CMS waiver amendment to invest in comprehensive OPWDD reform in a manner modeled on MRT
($250M).
 Additional savings produced by the Affordable Care Act (ACA) ($100M).
Several investments to the Health Care Industry were also included in the 30-Day Amendments. The 2% AcrossThe-Board reduction implemented during the beginning of the MRT will be restored. Restoration will begin in the
fourth quarter of 2013-14. Also, most of the Affordable Care Act (ACA) savings will be reinvested in health care.
More detailed information regarding the Partnership Solution can be found on of Health’s website at:
http://www.health.ny.gov/health_care/medicaid/redesign/
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2012-13 Annual Growth
In the April Report, DOH and DOB provided an explanation of the $600 million forecasted growth in the program.
The components of the growth are:
Price increases primarily driven by fee-for-service rate increases (some still awaiting CMS approval) and
Medicaid Managed Care/Family Health Plus premium increases which will be implemented throughout the
year (+$363 million);
Enrollment growth will increase between 90,000 to 120,000 recipients over last year (+$433 million);
One-time actions from the prior fiscal year that impact year-to-year growth (i.e., loss of enhanced FMAP
and 53rd Medicaid weekly cycle) (+$192 million); offset by,
Accounts receivable balance (amount owed from providers for rate reductions implemented last year) will
be reduced nearly in half (-$259 million); and lastly,
MRT Phase I savings will annualize and new MRT Phase II initiatives will be implemented (-$129 million).
Hurricane Sandy Update
In late October, Hurricane Sandy battered New York City, Long Island, and other downstate counties. According to
reports per NYS Office of Emergency Management and NYC Disaster Management staff, there were over 150
agencies and providers that were either closed or significantly impacted by the storm surge. The State had
submitted a request to provide immediate cash relief, but that was not approved by CMS. On January 29, 2013,
President Obama signed P.L.113-2 providing supplemental appropriations primarily for Hurricane Sandy disaster
assistance. This bill includes approximately $50 billion in direct governmental spending, aid to individuals, and
grants to state and local governments and other entities. The State is working with all affected agencies to
determine how these funds may be utilized to assist affected parties. The funds are divided into several
components for different specific purposes. The Department in conjunction with OMH, OWPDD, and OASAS has
forwarded data from the impact survey sent out in December to the Governor's Office to assist them in determining
needs for the health care community related to Hurricane Sandy. In addition the Office of Health Insurance
Programs is working with providers and their associations to reimburse costs incurred related to the treatment of
Medicaid recipients as a result of this emergency following billing policies developed with this work group.
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Medicaid Global Spending Cap
2012-13
$18,000
$16,000
$14,000
$15,912
Projected
Actual
$12,000
Millions
$10,000
$8,000
$6,000
$4,000
$2,000
$0
Medicaid Spending
January 2013
(dollars in millions)
Category of Service
Total Fee For Service
Inpatient
Outpatient/Emergency Room
Clinic
Nursing Homes
Other Long Term Care
Non-Institutional
Medicaid Managed Care
Family Health Plus
Medicaid Administration Costs
Medicaid Audits
All Other
Local Funding Offset
TOTAL
Estimated
$9,581
$2,605
$459
$533
$2,888
$1,541
$1,556
$8,016
$809
$453
($255)
$834
($6,156)
$13,282
Actual
$9,484
$2,569
$424
$530
$2,874
$1,544
$1,543
$8,023
$797
$412
($275)
$812
($6,156)
$13,097
Variance
($96)
($36)
($35)
($3)
($14)
$3
($12)
$7
($12)
($42)
($20)
($22)
$0
($185)
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Results through January - Variance Highlights

Lower Fee-for-Service Spending: Through January, Medicaid spending in major fee-for-service categories is
$96 million below projections as follows:
o Inpatient hospital spending is $36 million below projections, a result of several different payment factors.
Although utilization is on target with projections, billing for Inpatient services that, in general, have higher
payment rates are down, whereas Graduate Medical Education (GME) claims related to Medicaid Managed
Care recipients are up. GME rates of payment tend to be lower than case payment rates. Also, an
unexpected number of voided claims have occurred since November due to the retroactive re-processing of
psychiatric claims under the new reform methodology. As a result, many hospitals have experienced
significant reductions in their weekly payments. As hospitals amend their voided claims, it is expected that the
majority of those funds will be paid back to providers, thus reducing the spending variance. Lastly, there has
been a delay in claims billings as a result of Hurricane Sandy which we expect will catch up as the affected
facilities restore their services.
o Outpatient/Emergency Room spending is $35 million below estimates which reflects lower than expected
claims billed and a lower average payment per claim than anticipated.
o Clinic spending is $3 million below projections.
o Nursing Home spending is $14 million below projections, a result of slightly lower than projected utilization.
o Other Long Term Care services spending, which includes Personal Care, Home Health, Home Nursing, and
the Assisted Living programs, is $3 million above projections. The variance reflects lower than projected
spending in Home Health ($144 million), Home Nursing ($47 million) and Assisted Living ($2 million) offset by
higher than projected spending in Personal Care ($196 million).
The variances for the subcategories within the Other Long Term Care services are attributable to the
assumptions used for the movement of long term care recipients to a managed care setting. The
Department’s preliminary estimates assumed that the majority of long term care recipients and costs
transitioning into the Managed Long Term Care program would come from the Personal Care sector. The
latest findings have demonstrated the opposite; close to 90 percent of the long term care fee-for-service
Medicaid costs that have transitioned into managed care were previously from Home Health and Home
Nursing.
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For Home Health and Home Nursing, the cumulative spending below target is also impacted by the initial
delay in billing as a result of the implementation of the episodic payment system; with the difference in provider
billing patterns that result from the episodic billing for a 60 day period versus the prior consistent weekly billing
of hourly and per visit claims.
o Non-Institutional fee-for-service spending (includes pharmacy, transportation, supplemental medical
insurance, etc.) is $12 million below projections. The variance is primarily due to lower than projected
spending in pharmacy, a result of lower than expected utilization caused by services shifting into Managed
Care plans.

Medicaid Managed Care Spending: Through January, Medicaid Managed Care spending is on target with
projections.

Family Health Plus Spending: Through January, Family Health Plus spending is $12 million below
projections. To date, enrollment for Family Health Plus is slightly lower than expected, 1.1%.

Medicaid Administration Costs: Through January, local district Medicaid Administration spending is $42
million below projections. This surplus is consistent with efforts undertaken by the State to take over the
Medicaid Administration program from localities. The 2012-13 Enacted Budget capped local administrative
costs at the 2011-12 levels and initiated a State phased-in take-over of administrative functions, such as
processing of Family Planning Benefit Program applications, transportation management, and other tasks that
were previously executed by local districts and counties. The State recently expanded State Disability Review
Team Disability Reviews to one additional county, fully implemented the transportation management in New
York City, and centralized resolution of reported deaths in selected counties in January. Preliminary results
indicate that all county claims are anticipated to be paid for in the current Fiscal Year.

Medicaid Audits: Through January, the spending offsets from Medicaid audit recoveries are $20 million
higher than expected.

Other State Agency (OSA) Spending: Medicaid spending by Other State Agencies (OSA) is running $60
million below projections through January. The variance is primarily attributable to lower than projected
spending in the Office for People with Developmental Disabilities which is associated with the processing of
certain retroactive rate packages ($43 million). However, this under spending is offset by an increase in the
account receivable balance which will be recouped over subsequent months ($17 million net under spending
through January). State share spending is processed by the Department of Health and subsequently
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transferred from the other agency budgets. The local share of these services is funded principally by counties
and NYC and to the extent costs exceed the capped local contribution, funding is through the Department of
Health. These services include programs administered through the Office for People with Developmental
Disabilities, the Office of Mental Health, the Office of Children and Family Services and the Office of Alcoholism
and Substance Abuse Services.
Accounts Receivable
The accounts receivable balance for retroactive rates owed to the State through the end of January is $359 million.
This reflects $218 million of recoupments through January. It should be noted that to the extent recoveries are not
made, there will be a direct impact on the Medicaid Global Spending Cap. The Department of Health plans to
continue to work collectively with the hospitals, nursing homes, and home care providers asking for voluntary
payment of outstanding liabilities as a means to avoid interest costs and help mitigate the adverse impact of
outstanding receivable balances on the Medicaid Global Spending Cap. The Department will closely monitor the
accounts receivable balances each month.
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Enrollment
Medicaid total enrollment reached 5,277,482 enrollees at the end of January 2013. This reflects an increase of
roughly 229,200 enrollees, or 4.5%, since March 2012.
Medicaid Enrollment
5,450,000
5,350,000
5,250,000
5,150,000
Total Medicaid Enrollees
5,050,000
4,950,000
4,850,000
4,750,000
Source: NYS DOH/OHIP Medicaid Enrollment Database
*Most current four months counts are adjusted by lag factors (2.92%, 1.12%, 0.43% and 0.15%,
respectively)
Medicaid Managed Care enrollment in January 2013 (includes FHP and Managed LTC) reached 3,942,355
enrollees, an increase of around 351,000 enrollees, or 9.8%, since March 2012.
Medicaid Managed Care
4,000,000
3,500,000
3,000,000
Total Managed Care
(75% of Total Enrollees)
2,500,000
2,000,000
1,500,000
Fee for Service
(25% of Total Enrollees)
1,000,000
Source: NYS DOH/OHIP Medicaid Enrollment Database and Managed Care Roster
*Includes FHP, Managed LTC, Primary Care Partial Capitation Provider, Partial Managed LTC,
PACE, Medicaid Advantage, Medicaid Advantage Plus and HIV SNP.
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Beginning in November 2011, Medicaid coverage expanded for children under the age of 19 whose family income
did not exceed 133 percent of the Federal Poverty Level. This accounts for 81,700 of the new 229,200 Medicaid
enrollees and 81,700 of the 351,000 new Medicaid Managed Care enrollees since March 2012. Importantly, the
Federal government ensures that these children who were previously enrolled in the Child Health Plus (CHP)
program will continue to be funded through CHP, and as such, will not incur additional costs under the Medicaid
Global Spending Cap.
Regional Spending Data
The Global Cap legislation requires the Department to publish actual state Medicaid spending by region. The
regions selected are based on the Governor’s eleven economic development areas. The following link shows
provider spending that occurs within the Medicaid claiming system (eMedNY) through January 2013 for each
region.
Detailed regional information can be found on the Department of Health’s website at:
http://www.health.ny.gov/health_care/medicaid/regulations/global_cap/regional/index.htm
Monthly Spending Projections
The monthly spending forecast was developed to reflect:

Actual spending patterns for State Fiscal Year 2011-12 adjusted for one-time spending that is not expected to
recur in SFY 2012-13;

Anticipated increases in health care prices and estimated changes in service utilization in SFY 2012-13; and

The achievement of savings generated from the annualization of MRT Phase I actions as well as new Phase II
actions over time.
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